5.6 Documentation

Sample Documentation:

11/17/20XX 1030

The NG tube insertion procedure was explained to the client. Prior to the NG tube insertion, hypoactive bowel sounds were present in all 4 quadrants, and the abdomen was slightly distended with no tenderness noted upon palpation. Client reported nausea and bloating. A 14 French, Salem NG tube was inserted via the left nostril at 1008 on 11/17/20XX. Placement was verified by X-ray and then the NG tube was attached to low intermittent suction as ordered. Tube was secured to the nose with exit point at 53 cm. Gastric drainage was pale green with pH of 4. Client tolerated the procedure without complication and reports decreased nausea. Client is resting comfortably in bed with no complaints of pain.

Jaimie Salvator, RN